4 Tiers

The evidence supporting the substance abuse prevention strategies in the literature varies widely. These differences do not always mean that one strategy is intrinsically better than another. They may reflect the fact that some strategies have not been as thoroughly studied as others or have not been evaluated for application to college drinkers. To provide a useful list that accounts for the lack of research as well as negative findings, Task Force members placed prevention strategies in descending tiers on the basis of the evidence available to support or refute them.

Tier 1: Evidence of Effectiveness Among College Students

Strong research evidence (two or more favorable studies available) supports the strategies that follow. All strategies target individual problem, at-risk, or alcohol-dependent drinkers. Their efficacy as part of a campus-wide strategy has not been tested.

Strategy: Combining cognitive-behavioral skills with norms clarification and motivational enhancement interventions. Cognitive-behavioral skills training strives to change an individual's dysfunctional beliefs and thinking about the use of alcohol through activities such as altering expectancies about alcohol's effects, documenting daily alcohol consumption, and learning to manage stress.

Norms or values clarification examines students' perceptions about the acceptability of abusive drinking behavior on campus and uses data to refute beliefs about the tolerance for this behavior as well as beliefs about the number of students who drink excessively and the amounts of alcohol they consume.

As its name implies, motivational enhancement is designed to stimulate students' intrinsic desire or motivation to change their behavior. Motivational enhancement strategies are based on the theory that individuals alone are responsible for changing their drinking behavior and complying with that decision (Miller et al., 1992). In motivational enhancement interventions, interviewers assess student alcohol consumption using a formal screening instrument. Results are scored and students receive nonjudgmental feedback on their personal drinking behavior in comparison with that of others and its negative consequences. Students also receive suggestions to support their decisions to change.

Research indicates that combining the three strategies is effective in reducing consumption (Larimer and Cronce, 2002). One example of such an approach is a program using motivational enhancement, developed by Marlatt. The program, the Alcohol Skills Training Program (ASTP), is a cognitive-behavioral alcohol prevention program that teaches students basic principles of moderate drinking and how to cope with high-risk situations for excessive alcohol consumption (Fromme et al., 1994). The ASTP is designed for group administration and includes an alcohol expectancy challenge component. Controlled outcome studies show that the ASTP significantly reduces drinking rates and associated problems for both 1-year (Kivlahan et al., 1990) and 2-year follow-up periods (Baer et al., 1992).

Strategy: Offering brief motivational enhancement interventions. Students who receive brief (usually 45-minute), personalized motivational enhancement sessions, whether delivered individually or in small groups, reduce alcohol consumption. This strategy can also reduce negative consequences such as excessive drinking, driving after drinking, riding with an intoxicated driver, citations for traffic violations, and injuries (D'Amico and Fromme, 2000; Larimer and Cronce, 2002; Marlatt et al., 1998; Monti et al., 1999). This approach has been used successfully in medical settings (Dimeff and McNeeley, 2000; Monti et al., 1999). An effective brief intervention has been developed at the University of Washington. This brief intervention for high-risk drinkers is based on the ASTP program and is known as the BASICS program: Brief Alcohol Screening and Intervention for College Students (Dimeff et al., 1999). BASICS is administered in the form of two individual sessions in which students are provided feedback about their drinking behavior and given the opportunity to negotiate a plan for change based on the principles of motivational interviewing. High-risk drinkers who participated in the BASICS program significantly reduced both drinking problems and alcohol consumption rates, compared to control group participants, at both the 2-year follow-up (Marlatt et al., 1998) and 4-year outcome assessment periods (Baer et al., 2001). BASICS has also been found to be clinically significant in an analysis of individual student drinking changes over time (Roberts et al., 2000).

Strategy: Challenging alcohol expectancies. This strategy works by using a combination of information and experiential learning to alter students' expectations about the effects of alcohol so they understand that drinking does not necessarily produce many of the effects they anticipate such as sociability and sexual attractiveness (Darkes and Goldman, 1993, 1998; Jones et al., 1995). The research conducted to date indicates that the positive effects of this strategy last for up to 6 weeks in men, but additional research is under way to verify and extend this approach to women and for longer time periods.

Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments

The Task Force recommends that college presidents, campus alcohol program planners, and student and community leaders explore the strategies listed below because they have been successful with similar populations, although they have not yet been comprehensively evaluated with college students (Hingson et al., 1996b; Holder et al., 2000; Saltz and Stangetta, 1997; Voas et al., 1997; Wagenaar et al., 2000). These environmental strategies are not guaranteed to alter the behavior of every college student, but they can help change those aspects of the campus and community culture that support excessive and underage alcohol use.

"Student safety is of paramount importance; we simply have to make certain that our [alcohol prevention] program is working."

Strategy: Increased enforcement of minimum drinking age laws (Toomey and Wagenaar, 2002; Wagenaar and Toomey, 2002). The minimum legal drinking age (MLDA) law is the most well-studied alcohol control policy. Compared to other programs aimed at youth in general, increasing the legal age for purchase and consumption of alcohol has been the most successful effort to date in reducing underage drinking and alcohol-related problems. Most studies suggest that higher legal drinking ages reduce alcohol consumption, and over half found that a higher legal drinking age is associated with decreased rates of traffic crashes. Studies also indicate that policies are less effective if they are not consistently enforced. Moreover, the certainty of consequences is more important than severity in deterring undesirable behavior.

The benefits of the MLDA have occurred with minimal enforcement, yet studies of the effects of increased enforcement show that it is highly effective in reducing alcohol sales to minors (Wagenaar and Toomey, 2002). Increased enforcement—specifically compliance checks on retail alcohol outlets—typically cuts rates of sales to minors by at least half (Grube, 1997; Lewis et al., 1996; Preusser et al., 1994; Wagenaar et al., 2000). Efforts to reduce the use of false age identification and tighter restrictions on "home delivery" of alcohol may also help enhance the effectiveness of this law.

Strategy: Implementation, increased publicity, and enforcement of other laws to reduce alcohol-impaired driving. Injury and deaths caused by alcohol-impaired driving and related injuries and deaths can be reduced by lowering legal blood alcohol limits to .08 percent for adult drivers (Dee, 2001; Hingson et al., 1996a, 2000; Shults et al., 2001; Voas et al., 2000); setting legal blood alcohol content (BAC) for drivers under age 21 at .02 percent or lower (Hingson et al., 1994; Wagenaar et al., 2001); using sobriety check points (Castle et al., 1995; Lacey et al., 1999; Shults et al., 2001); providing server training intervention (Gliksman et al., 1993; Lang et al., 1998; Russ and Geller, 1987; Saltz, 1987; Shults et al., 2001); and instituting administrative license revocation laws (Klein, 1989; Voas et al., 2000; Zador et al., 1989). Safety belt laws, particularly primary enforcement belt laws, have been shown in numerous studies to reduce traffic deaths and injuries (Dinh-Zaar et al., 2001). When California changed from a secondary to a primary enforcement belt law that permits police to stop vehicles and give a citation simply because an occupant was not belted, safety belt use rates increased 39 percent among drivers with BAC of .10 percent or higher compared to 23 percent overall (Lange and Voas, 1998). This indicates that primary enforcement belt laws can prevent many alcohol-related traffic fatalities. Comprehensive community interventions have also shown that increased enforcement and publicity of laws to reduce alcohol-impaired driving have produced significant reductions in the types of motor vehicle crashes most likely to involve alcohol (Holder et al., 2000) and alcohol-related traffic deaths (Hingson et al., 1996b).

Strategy: Restrictions on alcohol retail outlet density (Scribner et al., 1995; Gruenewald et al., 1993). Studies of the number of alcohol licenses or outlets per population size have found a relationship between the density of alcohol outlets, consumption, and related problems such as violence, other crime, and health problems (Toomey and Wagenaar, 2002). One study, targeting college students specifically, found higher levels of drinking and binge drinking among underage and older college students when a larger number of businesses sold alcohol within one mile of campus (Chaloupka and Wechsler, 1996). Numbers of outlets may be restricted directly or indirectly through policies that make licenses more difficult to obtain such as increasing the cost of a license.

Strategy: Increased prices and excise taxes on alcoholic beverages. A substantial body of research has shown that higher alcoholic beverage prices or taxes are associated with lower levels of alcohol consumption and alcohol-related problems (Leung and Phelps, 1993; Kenkel and Manning, 1996; Chaloupka et al., 1998; Cook and Moore, 2002). However, estimates of the extent to which consumption or problems change in response to a given price or tax change cover a fairly wide range. Some studies have examined these effects among young people separately from the general population. Most such studies have found that young people exhibit significant responses to price or tax changes, in some cases larger than responses estimated for the general population (Grossman et al., 1987; Coate and Grossman, 1988; Kenkel, 1993; Sutton and Godfrey, 1995; Ruhm, 1996; Grossman et al., 1998). An exception is the recent study by Dee (1999), which found only small and statistically insignificant effects of beer taxes on teens' drinking behavior. In addition, Chaloupka and Wechsler (1996) found that higher beer prices tend to decrease drinking and binge drinking among U.S. college students, but that price is a relatively weak tool for influencing these behaviors among college students, especially males. In a study of the population aged 17 and older, Manning et al. (1995) found that consumption was responsive to price for all but the 5 percent of drinkers with the heaviest consumption, who exhibited no significant price response.

A number of studies have examined the effects of alcohol prices or taxes on traffic crash fatalities and other alcohol-related problems. Most such studies have reported that higher taxes or prices were associated with significant reductions in traffic crash fatalities or drunk driving, particularly among younger drivers and during nighttime hours (Saffer and Grossman, 1987; Chaloupka et al., 1993; Kenkel, 1993; Ruhm, 1996). A few recent studies have questioned these findings. Dee (1999) found some evidence that beer taxes tend to reduce teen traffic fatalities, but concluded that those results were not robust and should be viewed with skepticism. Young and Likens (2000) found no significant effects of beer taxes on traffic crash fatality rates, either for young drivers or the general population. Mast et al. (1999) found mixed results, with several analyses indicating significant but relatively small effects of beer taxation on traffic fatalities. Other research has found associations between higher alcoholic beverage taxes and lower rates of some types of violent crime (Cook and Moore, 1993a), reduced incidence of physical child abuse committed by women (Markowitz and Grossman, 2000), and lower rates of sexually transmitted diseases (Chesson et al., 2000), as well as with increases in college graduation rates (Cook and Moore, 1993b).

Further research is needed to clarify the effects that alcoholic beverage prices or taxes have on different drinking behaviors, health-related outcomes, and population sub-groups, and to reconcile conflicting findings that have appeared in the literature. To date, however, the weight of evidence clearly suggests that higher prices and taxes can help to reduce alcohol consumption and alcohol-related problems.

Strategy: Responsible beverage service policies in social and commercial settings (Saltz and Stangetta, 1997; Holder et al., 1997b). Studies suggest that bartenders, waiters, and others in the hospitality industry would welcome written policies about responsible service of alcohol and training in how to implement them appropriately. Policies could include serving alcohol in standard sizes, limiting sales of pitchers, cutting off service of alcohol to intoxicated patrons, promoting alcohol-free drinks and food, and eliminating last-call announcements. Servers and other staff could receive training in skills such as slowing alcohol service, refusing service to intoxicated patrons, checking age identification, and detecting false identification. To prevent sales to underage patrons, it is important to back identification policies with penalties for noncompliance.

Strategy: The formation of a campus and community coalition involving all major stakeholders may be critical to implement these strategies effectively. A number of comprehensive community efforts have been designed to reduce alcohol and other substance use and related negative consequences among underaged youth, including college students, and among adults (Chou et al., 1998; Hingson et al., 1996b; Holder et al., 1997b; Pentz et al., 1989; Perry et al., 1996; Treno and Holder, 1997; Wagenaar et al., 2000); and their outcomes demonstrate the potential effectiveness of this approach in college communities. For example, the Community Trials Program (Grube, 1997; Holder and Treno, 1997; Holder et al., 1997a, b; Holder and Reynolds, 1997; Holder et al., 2000; Treno and Holder, 1997; Reynolds et al., 1997; Saltz and Stangletta, 1997; Voas et al., 1997), which focused on alcohol trauma in the general population, resulted in a significant decline in emergency room admissions for alcohol-related assault. Both this program and Communities Mobilizing for Change (CMCA) (Wagenaar et al., 1999, 2000), which was designed specifically to reduce drinking among young people, resulted in reduced alcohol sales to minors. In the CMCA project young people ages 18 to 20 reduced their propensity to provide alcohol to other teens and were less likely to try to buy alcohol, drink in a bar, or consume alcohol. The Massachusetts Saving Lives Program (Hingson et al., 1996b), designed to reduce drunk driving and speeding in the general population, produced relative declines in alcohol-related fatal crashes involving drivers 15 to 25 years of age.

This approach reframes the issue as a community problem, not simply a college problem, brings together the range of players needed to address it, and sets the stage for cooperative action. In addition to college presidents and campus administrators, stakeholders in campus-community coalitions include student groups, faculty, staff, community leaders, law enforcement, and representatives from hospitality and alcohol beverage industries (Hingson and Howland, 2002). Research shows that promoting community ownership of programs enhances success (Holder et al., 1997a). On that basis, active campus and community coalitions can be expected to build support for addressing underage and excessive college drinking; help assure that strategies used respond to genuine community needs; maintain and, ultimately, institutionalize effective strategies; and evaluate and disseminate the results of the coalition's activities to other college communities (Hingson and Howland, 2002).

Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation

The Task Force recognizes that a number of popular strategies and policy suggestions make sense intuitively or have strong theoretical support. Many also raise researchable questions that may be crucial in reducing the consequences of college student drinking. Although the Task Force is eager to see these strategies implemented and evaluated, it cautions interested schools to assemble a team of experienced researchers to assist them in the process.

The Task Force recommends that schools considering any of these strategies incorporate a strong evaluation component to test their viability in actual practice. Every strategy that appears below targets the student population as a whole.

"Excessive student drinking contributes to failed academic performance ranging from missed classes to attrition. At the same time, many colleges and universities unwittingly help create a culture of student drinking by scheduling no classes on Friday, thereby creating three-day weekends, and by grade inflation which tolerates and even rewards minimal student performance."

Strategy: Adopting campus-based policies and practices that appear to be capable of reducing high-risk alcohol use. The following activities are particularly appealing because straightforward and relatively brief evaluations should indicate whether they would be successful in reducing high-risk drinking on a particular campus.

• Reinstating Friday classes and exams to reduce Thursday night partying; possibly scheduling Saturday morning classes.
   
• Implementing alcohol-free, expanded late-night student activities.
   
• Eliminating keg parties on campus where underage drinking is prevalent.
   
• Establishing alcohol-free dormitories.
   
• Employing older, salaried resident assistants or hiring adults to fulfill that role.
   
• Further controlling or eliminating alcohol at sports events and prohibiting tailgating parties that model heavy alcohol use.
   
• Refusing sponsorship gifts from the alcohol industry to avoid any perception that underage drinking is acceptable.
   
• Banning alcohol on campus, including at faculty and alumni events.

Strategy: Increasing enforcement at campus-based events that promote excessive drinking (DeJong and Langenbahn, 1996; Gulland, 1994). Campus police can conduct random spot checks at events and parties on campus to ensure that alcohol service is monitored and that age identification is checked. It may be important for non-students to enforce these campus policies. Resident assistants and others charged with developing close supportive relationships with students might find it difficult to enforce alcohol-related rules and regulations consistently and uniformly.

Strategy: Increasing publicity about and enforcement of underage drinking laws on campus and eliminating "mixed messages." As indicated previously, active enforcement of minimum legal age drinking laws results in declines in sales to minors (Grube, 1997; Lewis et al., 1996; Preusser et al., 1994; Wagenaar et al., 2000). Lax enforcement of State laws and local regulations on campus may send a "mixed message" to students about compliance with legally imposed drinking restrictions. Creative approaches are needed to test the feasibility of this strategy (DeJong and Langford, 2002).

"We dare not let alcohol blemish your bright promise."

Strategy: Consistently enforcing disciplinary actions associated with policy violations (DeJong and Langford, 2002). Inconsistent enforcement of alcohol-related rules may suggest to students that "rules are made to be broken." To test the effectiveness of this approach would likely require staff and faculty training, frequent communication with students, and the implementation of a research component.

Strategy: Conducting marketing campaigns to correct student misperceptions about alcohol use (Berkowitz, 1997; Clapp and McDonnell, 2000; DeJong and Linkenbach, 1999; Johannessen et al., 1999; Page et al., 1999; Perkins, 1997, 2002; Perkins and Wechsler, 1996). On the basis of the premise that students overestimate the amount of drinking that occurs among their peers and then fashion their own behavior to meet this perceived norm, many schools are now actively conducting "social norming" campaigns to correct many of these misperceptions.

Strategy: Provision of "safe rides" programs (DeJong, 1995). Safe rides attempt to prevent drinking and driving by providing either free or low-cost transportation such as taxis or van shuttles from popular student venues or events to residence halls and other safe destinations. Safe rides are usually restricted to students, faculty, staff, and a limited number of "guests." Safe rides sponsors often include student government, Greek Councils, student health centers, campus police, Mothers Against Drunk Driving chapters, and other local community organizations, agencies, and businesses. They have been criticized as potentially encouraging high-risk drinking, and this possibly should be considered in design, promotion, and monitoring.

Strategy: Regulation of happy hours and sales (Toomey and Wagenaar, 2002). Happy hours and price promotions—such as two drinks for the price of one or women drink for free—are associated with higher consumption among both light and heavy drinkers. Research shows that as the price of alcohol goes up, consumption rates go down, especially among younger drinkers. Because many bars surrounding campuses attract students by promoting drink specials, restrictions on happy hours have the potential to reduce excessive consumption off campus. If colleges and universities have a licensed establishment on campus, drink specials could be prohibited or promotion of alcohol-free drinks and food specials could be encouraged. In nonlicensed settings on campus that serve alcohol, event planners could opt to limit the amount of free alcohol that is available and eliminate all self-service. Schools could also limit alcohol use to weekends or after regular class hours in an effort to separate drinking from activities more closely aligned with the core academic mission.

Strategy: Informing new students and their parents about alcohol policies and penalties before arrival and during orientation periods. There is some anecdotal evidence that experiences during the first 6 weeks of enrollment affect subsequent success during the freshman year. Because many students begin drinking heavily during this time, they may be unable to adapt appropriately to campus life. Alerting parents and students to this possibility early on (e.g., through preadmission letters to parents and inclusion of information in orientation sessions and in presidents' and student leaders' welcoming speeches) may help prevent the development of problems during this critical, high-risk period.

Tier 4: Evidence of Ineffectiveness

The Task Force recognizes that it is difficult or impossible to "prove" that a specific intervention approach is universally ineffective. Nevertheless, when there are consistent findings across a wide variety of well-designed studies, it is possible to conclude that an approach is not likely to be effective and that limited resources should be used in other ways. Additionally, if there is strong evidence that an intervention approach is actually harmful or counterproductive, recommendations not to use it can be made based on fewer studies.

The Task Force also notes that some interventions may be ineffective when used in isolation, but might make an important contribution as part of a multicomponent integrated set of programs and activities (Larimer and Cronce, 2002). However, until there is evidence of a complementary or synergistic effect resulting from inclusion with other strategies, college administrators are cautioned against making assumptions of effectiveness without scientific evidence.

Strategy: Informational, knowledge-based, or values clarification interventions about alcohol and the problems related to its excessive use, when used alone (Larimer and Cronce, 2002; Maddock, 1999). This strategy is based on the assumption that college students excessively use alcohol because they lack knowledge or awareness of health risks and that an increase in knowledge would lead to a decrease in use. Although educational components are integral to some successful interventions, they do not appear to be effective in isolation. Despite this evidence, informational/educational strategies are the most commonly utilized techniques for individually focused prevention on college campuses (DeJong and Langford, 2002; Larimer and Cronce, 2002).

Strategy: Providing blood alcohol content feedback to students. This strategy uses breath analysis tests to provide students accurate information on their BAC. It could be used as part of a research evaluation or to dissuade students from driving while under the influence or continuing to drink past intoxication. Providing this information to students who are drinking must be approached with caution. Some researchers have found that the presence of immediate breath analysis feedback can actually encourage excessive drinking when students make a contest of achieving high BACs (personal communications from Scott Geller, 2002 and Robert Voas, 2002). If BAC feedback is to be provided in naturalistic settings, the procedure should be carefully monitored for adverse effects and adjusted as necessary.

Last reviewed: 7/11/2007